Rare cause of recurrent fever of unknown origin: Acute obstructive suppurative pancreatic ductitis after pancreaticojejunostomy

A rare case of acute obstructive suppurative pancreatic ductitis (AOSPD) which developed pyogenic spondylitis

Acute obstructive suppurative pancreatic ductitis (AOSPD) is an acute suppuration of the pancreatic duct. Endoscopic retrograde cholangiopancreatography (ERCP) drainage and intravenous antibiotics treatment is the mainstay of therapy. Herein we describe an extremely rare case of AOSPD leading to pyogenic spondylitis. A 61-year-old male with a past medical history of chronic pancreatitis and diabetes mellitus presented to our hospital with abdominal and dorsal pain, fever, and shock status. Laboratory data showed severe inflammation, disseminated intravascular coagulation, and normal pancreatic enzymes. Computed tomography showed dilated main pancreatic duct and surrounding pancreatic abscesses. Spinal abnormalities were not detected at this point. He was initially diagnosed as infected pancreatic pseudocyst, but did not respond well to conservative intravenous antibiotic treatment. ERCP performed one week later revealed purulent pancreatic juice and the diagnosis was changed to AOSPD. Upon ERCP, we experienced technical difficulty in passing obstructing calculi. However, successful pancreatic drainage was achieved using new dilation and penetration devices. The patient responded quickly to drainage, but later developed pyogenic spondylitis. Our case highlights the difficulty of diagnosing AOSPD, the usefulness of new devices in urgent endoscopic drainage, and underscores the possibility of progression of pyogenic spondylitis even after adequate treatment.

A case of acute obstructive suppurative pancreatic ductitis complicated with acute cholangitis diagnosed only after the removal of a pancreatic duct stent

Acute obstructive suppurative pancreatic ductitis (AOSPD) is a rare complication of chronic pancreatitis that presents with high fever and abdominal pain. A 63-year-old man underwent plastic bile duct stent and plastic pancreatic duct stent (PDS) placement for benign stricture in the intrapancreatic bile and pancreatic ducts associated with chronic pancreatitis; the stents were routinely replaced. Seven months after the last replacement, the patient presented to our hospital with dark urine but without fever or abdominal pain. Subsequent blood tests revealed elevated levels of hepatobiliary enzymes, white blood cells, and C-reactive protein. However, the pancreatic enzyme levels remained unchanged, and abdominal computed tomography showed the absence of inflammation around the pancreas. He was initially diagnosed with acute cholangitis (AC) due to bile duct stent dysfunction and subsequently underwent emergency endoscopic retrograde cholangiopancreatography. As obstruction of the PDS was suspected, both bile duct stent and PDS were replaced. Although the collected bile did not exhibit purulence, a white purulent fluid was released after replacing the PDS. Cultures from the bile and pancreatic exudates revealed the presence of Klebsiella oxytoca. Consequently, the patient was diagnosed with AOSPD and AC. In this patient, endoscopic retrograde cholangiopancreatography was performed after the diagnosis of AC alone; however, relying solely on AC treatment might not have ameliorated the patient's condition. The patient did not complain of any abdominal pain and was diagnosed with AOSPD only after the replacement of his PDS. Our case suggests that AOSPD may be a pitfall in the identification of the source of inflammation in patients with chronic pancreatitis.